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ORIGINAL ARTICLE1

2 Positive Emotion Specificity and Mood Symptoms

3 in an Adolescent Outpatient Sample

4 June Gruber1 • Anna Van Meter2 • Kirsten E. Gilbert3 • Eric A. Youngstrom4•

5 Jennifer Kogos Youngstrom4• Norah C. Feeny5 • Robert L. Findling6

6

7 � Springer Science+Business Media New York 2016

8 Abstract Research on positive emotion disturbance has

9 gained increasing attention, yet it is not clear which

10 specific positive emotions are affected by mood symptoms,

11 particularly during the critical period of adolescence. This

12 is especially pertinent for identifying potential endophe-

13 notypic markers associated with mood disorder onset and

14 course. The present study examined self-reported discrete

15 positive and negative emotions in association with clini-

16 cian-rated manic and depressive mood symptoms in a

17 clinically and demographically diverse group of 401 out-

18 patient adolescents between 11 and 18 years of age.

19 Results indicated that higher self reported joy and contempt

20 were associated with increased symptoms of mania, after

21 controlling for symptoms of depression. Low levels of joy

22 and high sadness uniquely predicted symptoms of depres-

23 sion, after controlling for symptoms of mania. Results were

24 independent of age, ethnicity, gender and bipolar diagnosis.

25 These findings extend work on specific emotions impli-

26 cated in mood pathology in adulthood, and provide insights

27into associations between emotions associated with goal

28driven behavior with manic and depressive mood symptom

29severity in adolescence. In particular, joy was the only

30emotion associated with both depressive and manic

31symptoms across adolescent psychopathology, highlighting

32the importance of understanding positive emotion distur-

33bance during adolescent development. 34

35Keywords Positive emotion � Mania � Depression �

36Adolescence

37Introduction

38Bipolar spectrum disorders (referred to as BPSD) involve

39severe and recurring mood symptomatology, affecting up

40to 4 % of the general population over the course of a

41lifetime (e.g., Kessler et al. 2005) and roughly 2 % of

42adolescents world-wide (Van Meter et al. 2011). Severe

43mood symptoms include both manic symptoms associated

44with heightened and persistent elevated mood and

45increased reward seeking and goal pursuit, and depressive

46symptoms associated with depressed mood and decreased

47reward seeking and goal pursuit. Importantly, severe mood

48disturbance is ranked among the top ten causes of medical

49disability worldwide (Gore et al. 2011; Lopez et al. 2006).

50In many affected individuals, clear manifestations of manic

51and depressive mood symptoms do not appear until ado-

52lescence (Merikangas et al. 2007). During the adolescent

53period, pivotal maturational and environmental events

54occur that can trigger mood symptom onset according to

55neurodevelopmental models of mood disturbance (Good-

56win and Jamison 2007; Johnson and McMurrich 2006). It is

57important to examine this period of risk in order to improve

58diagnostic accuracy as well as to validate potential

A1 & June Gruber

A2 june.gruber@colorado.edu

A3 1 Department of Psychology and Neuroscience, University of

A4 Colorado Boulder, 1905 Colorado Avenue, 345 UCB,

A5 Muenzinger D321C, Boulder, CO 80309, USA

A6 2 Ferkauf Graduate School, Yeshiva University, New York,

A7 NY, USA

A8 3 Department of Psychiatry, Washington University in St.

A9 Louis, St. Louis, MO, USA

A10 4 Department of Psychology, University of North Carolina at

A11 Chapel Hill, Chapel Hill, NC, USA

A12 5 Case Western Reserve University, Cleveland, OH, USA

A13 6 Psychiatry and Behavioral Sciences, Johns Hopkins

A14 University, Baltimore, MD, USA

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59 endophenotypic markers of mood disturbance (Gottesman

60 and Gould 2003; Hasler et al. 2006).

61 Although research on mechanisms underlying mood

62 symptom severity in adolescence has expanded in the last

63 decade (e.g., Geller and Luby 1997; Youngstrom et al.

64 2008), continued efforts to identify psychosocial processes

65 are needed. These research efforts promise to improve risk

66 assessment, diagnosis, and early targeted treatment (e.g.,

67 Miklowitz and Chang 2008; Youngstrom et al. 2005).

68 Adolescence is a developmental period characterized by

69 many changes in affective experience, particularly height-

70 ened emotional reactivity. For instance, across negative

71 and positive affective stimuli, adolescents exhibit increased

72 subjective, physiological and neurobiological responding

73 compared with younger children and adults (Larson and

74 Lampman-Petraitis 1989; Quevedo et al. 2009; Somerville

75 et al. 2010; Silk et al. 2009). Subjective negative affect

76 appears to increase while subjective positive affect

77 decreases across adolescence (Larson et al. 2002; Henker

78 et al. 2002). Adolescents also report greater fluctuations in

79 daily emotional states, and this emotional variability itself

80 appears to change over adolescence as happiness, sadness

81 and anger all decline from early to late adolescence (Ma-

82 ciejewski et al. 2015). Given the numerous developmental

83 affective changes occurring during adolescence, we

84 specifically seek to investigate disturbances in emotional

85 valence systems in association with mood symptom dis-

86 turbance. Understanding these mechanisms may shed light

87 on inter-episode dysfunction and predict subsequent

88 relapse across psychiatric conditions and in BPSDs. This

89 emphasis is highly consistent with recent initiatives to

90 isolate disturbances in positive and negative valence sys-

91 tems through the NIMH Research Domain Criteria or

92 RDoC (e.g., Insel et al. 2010; Sanislow et al. 2010) and

93 more general models of positive emotion disturbance in

94 mood disorders (e.g., Hofmann et al. 2012; Stanton et al. in

95 press; Watson and Naragon-Gainey 2010).

96 Positive Emotions and Mood Symptom Disturbance:

97 Need for Specificity

98 Recent theories of mood disturbance, particularly for

99 BPSDs, implicate disturbances in positive emotional sys-

100 tems (e.g., Alloy and Abramson 2010; Gruber et al. 2011;

101 Johnson 2005). A hallmark feature of mania symptoma-

102 tology includes abnormally elevated and persistent positive

103 mood (American Psychiatric Association 2013). Descrip-

104 tive accounts of BPSDs prominently feature feelings of

105 ‘‘exuberance,’’ including experiences of excitement, inter-

106 est, and euphoria (Jamison 2005). More recent empirical

107 work converges with these observations to support the

108 centrality of positive emotional disturbances in bipolar

109 symptomatology (e.g., Gruber et al. 2014).

110However, most work on bipolar mood disturbance has

111traditionally emphasized broad dimensions of positive

112emotion assessment. This includes measurement of unidi-

113mensional constructs of ‘‘happiness’’ or ‘‘positive mood’’

114which lack specificity as to which particular emotions are

115impacted. Recent work in affective science, importantly,

116supports the validity of differentiating among a variety of

117functionally distinct positive emotions that differ in their

118function and response profile (Campos and Keltner 2014;

119Fredrickson 1998; Shiota et al. 2006; Tracy and Robins

1202004). Animal neuroscience models also encourage the

121utility of differentiating among distinct emotional states

122(Burgdorf and Panksepp 2006; Panksepp 1998). For

123example, joy (or happiness) is a reward-oriented emotion

124experienced when the environment signals an imminent

125improvement in resources, motivating the individual to

126acquire material resources and rewards such as joy (e.g.,

127joy; Berridge and Kringelbach 2008; Harmon-Jones and

128Gable 2009; Rolls 1999). Recent work on joy suggests it is

129uniquely associated with behavioral displays (i.e., Duch-

130enne smiles) that are robustly associated with self-reported

131joy (Keltner et al. 2003). Interest (or curiosity) is experi-

132enced when people encounter novel information usually

133consistent with their current worldview, which promote

134engagement with the environment and knowledge consol-

135idation (Fredrickson 1998; Izard 1977; Shiota et al. 2006).

136Although, anger—also a common feature of mania symp-

137tom severity (American Psychiatric Association 2013)—is

138negatively valenced, it shares many important neurophys-

139iological and behavioral features with positive emotions,

140including increased left hemispheric activation (Harmon-

141Jones and Allen 1998) and approach behavior tendencies

142towards the pursuit of goals (e.g., Carver 2004; Panksepp

1431998; Youngstrom and Izard 2008). As an approach-ori-

144ented emotion that mobilizes the body to overcome an

145obstacle impeding goal pursuit, anger is highly correlated

146with positive affectivity (Harmon-Jones 2003; Harmon-

147Jones and Gable 2009).

148Positive Emotion and Adolescent Mood Disturbance

149Understanding the concurrent relationship between positive

150emotions and mood symptom severity in adolescence is a

151high priority (e.g., Forbes and Dahl 2005; Gilbert 2012).

152Yet there is little known about the ways specific emotions

153map onto bipolar mood symptomatology. For example,

154although mania symptoms in adolescents have been asso-

155ciated with decreased neural activity and lower sensitivity

156to identifying happy faces (Diler et al. 2013; Guyer et al.

1572007; Rich et al. 2008), we know little about the specific

158positive emotions driving these responses. Moreover,

159adolescents at risk for or with depression demonstrate

160blunted reward responding that is associated with lower

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161 levels of daily positive emotion (Forbes et al. 2009) while

162 decreased happiness predicts the onset of depressive

163 symptoms (Neumann et al. 2011). Similar to adult litera-

164 ture, adolescent BPSDs are characterized by dysregulated

165 reward learning (Dickstein et al. 2009) and increased

166 reward sensitivity and approach-motivated behaviors being

167 associated with elevated manic symptoms (Gruber et al.

168 2013). Taken together, elevated reward-seeking positive

169 emotions (such as joy) and increased goal approach-moti-

170 vated emotions (including anger) appear to be linked to

171 manic and depressive symptoms in adolescents. This work

172 underscores the clinical significance of applying a discrete

173 emotions framework to mood disturbance in adolescence.

174 We suggest that a discrete emotions perspective may

175 advance the study of adolescent mood disturbance for

176 several reasons. First, application of a discrete framework

177 has yielded unique insights into better understanding both

178 manic and depressive symptom profiles in adults (e.g.,

179 Gruber et al. 2010, 2011). For example, adults at risk for

180 mania report specific elevations in high arousal positive

181 emotions (e.g., joy and interest), which prospectively pre-

182 dict increased mania symptom severity (Gruber et al.

183 2009). Moreover, adults with bipolar disorder report

184 greater approach-related emotions such as anger (Dutra

185 et al. 2014). These findings suggest a potential benefit by

186 applying similar methodological approaches to adoles-

187 cents. Second, this work is an important contributor to a

188 growing emphasis on understanding a variety of specific

189 positive (and negative) emotions experienced in adoles-

190 cence (e.g., Leibenluft 2011).

191 The Present Investigation

192 The present study examined whether theoretically relevant

193 positive emotions (and approach-related negative emo-

194 tions) represent an endophenotypic marker that contributes

195 to BPSD-related mood symptoms in adolescents. Given

196 growing emphasis on examining psychopathology pro-

197 cesses and associated symptoms dimensionally (Insel et al.

198 2010; Prisciandaro and Roberts 2011; Prisciandaro and

199 Tolliver 2015), we focused on mania and depression

200 symptom severity across a demographically diverse and

201 diagnostically heterogeneous adolescent outpatient sample.

202 Though we were primarily interested in examining the

203 associations between emotion and mood symptoms

204 dimensionally, we also performed a series of ANOVA

205 models as sensitivity analyses to assess whether there were

206 differences in average emotion scores across diagnostic

207 categories. These results complement the main analyses by

208 providing description of differences between diagnostic

209 groups, which have the advantage of familiarity, combined

210 with limitations due to heterogeneity of symptom presen-

211 tation and comorbidity. We also examined whether the

212emotion variables were associated with any of the demo-

213graphic variables (age, race, sex) using correlational anal-

214yses. Following these preliminary analyses, two primary

215aims were examined focusing on specific positive emotions

216as predictors of mania and depressive mood symptoms,

217respectively.

218First, based on the supposition that a central psychoso-

219cial factor associated with increased manic symptoms in

220adults involves increased approach or pursuit of goals in

221the environment (Alloy and Abramson 2010; Johnson

2222005; Meyer et al. 2001; Urosevic et al. 2008), we tested

223whether elevations of specific positive emotions associated

224with goal approach such as joy (also referred to as

225excitement or happy) (Shiota et al. 2006) were associated

226with increased symptoms of mania (Hypothesis 1a). We

227additionally examined whether elevations in the negative

228emotions of anger and contempt—closely associated with

229symptoms of mania and approach behavior in the pursuit of

230goals (Carver 2004; Harmon-Jones and Allen 1998)—were

231also associated with increased symptoms of mania (Hy-

232pothesis 1b). To test these hypotheses, we first controlled

233for symptoms of depression, and then examined whether

234symptoms of mania were uniquely associated with self-

235reported joy and anger, but not other positive or negative

236emotions. We also examined whether this same relation-

237ship held when examining these same approach-related

238emotions (i.e., joy, anger, contempt) versus all other

239emotions using a validated hierarchical linear regression

240model (Blumberg and Izard 1985, 1986).

241Second, based on the supposition that increased

242depressive symptoms in adults involves decreased pleasure

243and approach towards goals (Alloy and Abramson 2010;

244Davidson et al. 2002; Dillon and Pizzagalli 2010), we

245tested whether a deficit in the specific positive emotion of

246joy was associated with increased symptoms of depression

247(Hypothesis 2a). We additionally examined whether the

248specific negative emotion associated with reduced goal

249approach and pleasure, or sadness (Gable and Harmon-

250Jones 2010), was associated with increased symptoms of

251depression, based on work in children associating specific

252reports of sadness with increased depressive symptoms

253(Blumberg and Izard 1986) (Hypothesis 2b). To test these

254hypotheses, we first controlled for symptoms of mania, and

255then examined whether symptoms of depression were

256uniquely associated with self-reported joy (inversely), as

257well as the negative emotions of sadness, guilt and hostility

258also implicated with depressive symptoms. To gain greater

259specificity in our findings, we further examined whether

260this same relationship held examining these same four

261emotions (i.e., joy, sadness, guilt, hostility) versus all other

262emotions using a validated hierarchical linear regression

263model (Blumberg and Izard 1985, 1986). Finally, we used

264net regression (Cohen and Cohen 1983) to test whether any

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265 of the emotion variables or covariates (age sex, race) was

266 uniquely related to either manic or depressive symptoms

267 (See Table 5).

268 Methods

269 Participants

270 English-speaking adolescents and their primary caregiver

271 were recruited from two agencies: a consecutive case series

272 of youth presenting for services from an urban community

273 mental health center (n = 293) and youth who were

274 recruited for a variety of treatment studies for bipolar

275 disorder or for other childhood disorders from an academic

276 outpatient medical center (n = 108). The resulting sample

277 was demographically and diagnostically diverse; youth

278 from the community mental health center were more likely

279 to be Black [X2(4) = 219.38, p\ .0001] and youth from

280 the academic medical center were more likely to have a

281 BPSD diagnosis (X2(1) = 21.48, p\ .0001). Youth from

282 the community mental health center reported more con-

283 tempt [t(392) = 2.27, p = .024], youth from the academic

284 medical center reported more self-directed hostility

285 [t(159.37) = 2.92, p = .004]. There were no other signif-

286 icant differences in self-reported positive or negative

287 emotion or on other demographic variables. Potential par-

288 ticipants were excluded if they suffered from a pervasive

289 developmental disorder or cognitive disability. For the

290 present study, only youth aged 11–18 were included given

291 our specific a priori interest in adolescents’ self-reported

292 positive emotion. See Table 1 for demographic and clinical

293 characteristics.

294 Measures

295 DSM-IV-TR Diagnoses

296 All DSM-IV-TR diagnoses for adolescent participants were

297 made based on the information provided during a semi-

298 structured interview using the Kiddie Schedule for Affec-

299 tive Disorders and Schizophrenia—Present and Lifetime

300 version (KSADS-PL; Kaufman et al. 1997), along with the

301 mood disorders modules of the WASH-U-K-SADS (Geller

302 et al. 2001), which inquires more extensively about

303 symptoms of depression and mania. Raters were highly

304 trained (criterion of K[ .85 at the item level on five

305 interviews conducted by a reliable rater, and then K[ .85

306 on five interviews they led themselves) prior to conducting

307 interviews independently. Adolescent participants and their

308 parents (or caregivers) were interviewed sequentially by

309 the same rater, resolving discrepancies through re-inter-

310 viewing and clinical judgment. KSADS interviews resulted

311in DSM-IV diagnoses, including bipolar I, bipolar II,

312cyclothymic disorder, and bipolar not otherwise specified

313(NOS). The diagnosis of bipolar NOS was made in cases of

314hypomanic or manic symptoms that did meet criteria for

315another bipolar diagnosis, usually due to insufficient

316duration criteria. KSADS diagnoses were reviewed at a

317diagnostic consensus meeting, including at least one

318licensed clinician. The diagnostic consensus meeting fol-

319lowed the Longitudinal Evaluation of All Available Data

320(LEAD) standard of diagnosis to designate all diagnostic

Table 1 Demographic, clinical, positive emotion, and negative

emotion characteristics of adolescent outpatient sample

N = 401

Demographic

Age (years) 13.52 (1.83)

Female (%) 48.1

Race (%)

African American 68.1

Caucasian 24.7

Asian .5

Hispanic 2.0

Other 4.5

Clinical

Primary diagnosis (%)

Bipolar disorder 19.7

Depression 37.9

Disruptive behavior disorders 34.2

Other 8.2

Taking medication % 57.2

KDRS 24.17 (9.66)

KMRS 20.54 (9.40)

Positive emotion (percent of maximum possible)

Joy .56 (.24)

Interest .47 (.24)

Surprise .35 (.23)

Negative emotion (percent of maximum possible)

Sad .35 (.27)

Anger .47 (.27)

Self-directed hostility .24 (.25)

Shame .33 (.25)

Guilt .33 (.24)

Disgust .25 (.22)

Contempt .26 (.23)

Fear .21 (.24)

Shy .26 (.24)

KDRS KSADS Depression Rating Scale, KMRS KSADS Mania

Rating Scale, disruptive behavior disorders attention deficit hyper-

activity disorder, conduct disorder, oppositional defiant disorder and

disruptive disorder not otherwise specified. Values represent mean

values (with standard deviations in parentheses) unless otherwise

noted

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321 categories (Spitzer 1983). LEAD diagnoses took into

322 account the information collected through the K-SADS

323 interview, prior treatment history, family history, and

324 clinical judgment. For purposes of comparing groups of

325 diagnoses, we used a hierarchical system of categories

326 focused on mood disorders that has been used successfully

327 in previous studies of mood disorders in youth (Young-

328 strom et al. 2001; Youngstrom et al. 2008). Kappas for both

329 BPSD diagnosis (=.91) and for all diagnoses (=.95) were

330 good comparing consensus versus K-SADS diagnosis

331 (Youngstrom et al. 2005).

332 Mood Symptoms

333 The KSADS diagnostic interview assessed adolescents’

334 current and lifetime mood episodes. The KSADS Mania

335 Rating Scale (KMRS) and KSADS Depression Rating

336 Scale (KDRS) provided severity ratings of all mood

337 symptoms relevant to the DSM-IV criteria for mania and

338 depression (Axelson 2002). The KMRS scores ranged from

339 11 to 58 (M = 20.54, SD = 9.40) and KDRS scores ranged

340 from 12 to 52 (M = 24.17, SD = 9.66) with higher scores

341 indicating greater symptom severity. Scores on both the

342 KMRS and KDRS showed excellent internal consistency

343 (a = .92 and .86 in this sample, respectively). The present

344 analyses used current episode ratings, based on a summary

345 of youth and parent reported symptoms, in order to

346 examine more state-specific associations between current

347 mood symptom severity and emotional experiences in

348 adolescents.

349 Self-Reported Positive and Negative Emotion

350 Self-reported positive and negative emotions were pro-

351 vided by the adolescent using the Differential Emotions

352 Survey, Fourth Revision (DES-IV; Izard et al. 1993). Its 36

353 items are rated on a five-point scale from 1 (rarely or never)

354 to 5 (very often) asking respondents to indicate the extent

355 to which they experience each emotion in their daily life.

356 The present study used all 12 DES-IV emotion subscales:

357 Joy (a = .71), Interest (a = .68), Surprise (a = .67),

358 Sadness (a = .81), Anger (a = .79), Self-directed hostility

359 (a = .80), Shame (a = .73), Guilt (a = .70), Disgust

360 (a = .68), Contempt (a = .64), Fear (a = .84) and Shy-

361 ness (a = .75).

362 Procedure

363 Participants were enrolled consecutively. In rare cases

364 when referrals exceeded capacity, participants were chosen

365 at random. All parents (or caregivers) and adolescents

366 completed the informed consent process. All participants

367 were treatment seeking. The research interview occurred

368shortly after intake, or served as the intake if the partici-

369pants were enrolling directly into one of several treatment

370studies open during the course of the study. During the

371parent’s KSADS interview, the adolescent participant

372completed a series of questionnaires and other study

373components with a second research assistant, including the

374DES-IV. The adolescent then completed the KSADS with

375the same rater who had interviewed his/her parent on the

376same day.

377Results

378Preliminary Analyses

379Before testing our hypotheses, we first assessed bivariate

380correlations between the DES-IV scores and the demo-

381graphic variables. Results revealed that age was negatively

382correlated with joy (r = -.13, p = .01)—consistent with

383other recent reports (Uusitalo-Malmivaara 2014)—and

384positively correlated with sadness (r = .23, p\ .0005),

385anger (r = .20, p\ .0005), and self-directed-hostility

386(r = .13, p = .01). However, age was not correlated with

387interest (r = -.03, p = .51), disgust (r = .05, p = .35),

388fear (r = .00, p = .94), guilt (r = .04, p = .46), shame

389(r = .01, p = .80), or contempt (r = .10, p = .06). For

390sex, females reported higher scores on anger (p\ .0005),

391sadness (p\ .0005), contempt (p\ .0005), shyness

392(p\ .0005), guilt (p\ .0005), shame (p\ .0005), self-

393directed hostility (p = .001), disgust (p = .002), surprise

394(p = .014), and fear (p = .024). Females reported lower

395scores on joy (p = .04). For race, Caucasians reported

396higher contempt (p = .003) and self-directed hostility

397(p = .001) scores compared to non-Caucasian participants.

398In order to control for these demographic variables, we

399included age, gender, and race in Block 1 of the regression

400models. We also tested whether the average DES-IV scores

401varied by diagnostic group (BD, MDD, disruptive behavior

402disorders, and other disorders). There were between group

403differences for the following emotions: sadness (g2 = .07,

404p\ .0005), joy (g2 = .07, p\ .0005), self-directed hos-

405tility (g2 = .06, p\ .0005), anger (g2 = .05, p = .001),

406shame (g2 = .04, p = .002), guilt (g2 = .04, p\ .0005),

407shyness (g2 = .04, p = .003), and contempt (g2 = .03,

408p = .022). There were no differences in reported interest,

409surprise, disgust, or fear (all ps[ .05). Given our interest

410in measuring the relations between specific emotions and

411symptoms of mania and depression, independent of diag-

412nosis, we decided to include diagnosis (BPSD Y/N) in the

413final block of our regression analyses, in order to determine

414whether a bipolar diagnosis, above and beyond specific

415emotions, accounted for variance in manic or depressive

416symptoms. Finally, the relationship between symptoms of

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417 mania and depression was assessed, and consistent with

418 previous research in adolescents (Youngstrom et al. 2008)

419 mood symptom scores were positively correlated with each

420 other (r = .51, p\ .0005).

421 Aim 1: Emotion as a Predictor of Mania Symptoms

422 To assess the relationship between specific emotions with

423 symptoms of mania, we computed partial correlations

424 between symptoms of mania and each of the 12 discrete

425 DES-IV subscales while controlling for depression symp-

426 tom scores.1 As indicated in Table 2, symptoms of mania

427 were significantly associated with increased joy (but no

428 other positive emotion terms) and a trend towards

429 decreased sadness (but no other negative emotion terms).

430 To gain greater specificity in our findings, we further

431 examined whether symptoms of mania were uniquely

432 associated with approach-oriented emotions (i.e., joy,

433 anger, contempt), over and above other emotions (i.e.,

434 shyness, guilt, interest, surprise, disgust, self-directed

435 hostility, shame, fear). Towards this aim we conducted a

436 hierarchical multiple regression (Blumberg and Izard

437 1985, 1986) with Block 1 controlling for of age, gender

438 (Male = 0, Female = 1) and race (Caucasian = 0, Non-

439 Caucasian = 1) as well as depressive symptoms (KDRS).

440 Block 2 included the primary emotions of interest (joy,

441 anger, contempt)2 and Block 3 included all other emotions.

442 In Block 4, bipolar diagnosis (Y/N) was added to determine

443 whether diagnosis, above and beyond emotion, was asso-

444 ciated with manic symptoms. Missing data were deleted

445 listwise, multicollinearity diagnostics showed satisfactory

446 tolerance statistics, and Cook’s distance and standardized

447 DFBeta for each predictor revealed no influential cases

448 (Cook and Weisberg 1982; Myers 1990). As shown in

449 Table 3, KDRS scores and demographic variables (Block

450 1) were significant predictors of KMRS scores (R2= .29),

451 with control variables of age (b = -.10, p = .04) and

452 KDRS (b = .54, p\ .0005) predicting KMRS scores.

453 When mania-related emotions were added in Block 2, the

454 overall model was significant (R2= .32, DR2

= .03); both

455 joy (b = .12, p = .01) and contempt (b = .11, p = .04)

456 were positively related to KMRS scores. None of the

457emotions added in Block 3 were significant. In the final

458Block, bipolar diagnosis was a significant predictor

459(b = .69, p\ .001; DR2= .37). Age (b = -.08, p = .02),

460and KDRS scores (b = .27, p\ .0005) also remained

461significant in the final model. Guilt (b = -.09, p = .047)

462was the only significant emotion in the final model. In the

463final model, 70 % of the variance in mania scores was

464accounted for by the predictors.

465Aim 2: Emotion as a Predictor of Depression

466Symptoms

467To assess the relationship between specific positive emo-

468tions with symptoms of depression, we computed partial

469correlations between symptoms of depression and each of

470the 12 discrete DES-IV subscales while controlling for

471mania symptom scores. As indicated in Table 2, symptoms

472of depression were associated with decreased joy (but no

473other positive emotion terms) and increased sadness, anger,

474self-directed hostility, shame, guilty, disgust, fear and

475shyness (but not contempt).

476Again, we further examined whether symptoms of

477depression were uniquely associated with reduced

478approach-oriented emotions (i.e., joy) as well as negative

479emotions associated with loss and low approach-motivation

480and self-directed negative feelings common in depression

481(i.e., sadness, guilt, self-directed hostility), above and all

1FL01 1 Given that the individual emotion ‘interest’ may be dysregulated in

1FL02 mania (e.g., interest and engagement in goal-directed activities is a

1FL03 symptom of mania) and depression (e.g., decreased interest usually

1FL04 pleasurable activities is a symptom of depression) we also moved

1FL05 interest into Block 2 of regressions as a primary emotion of study.

1FL06 When doing so, Blocks and individual emotion significance remained

1FL07 unchanged and interest was not a significant predictor of symptoms.

2FL01 2 Given the high rate of mixed symptom presentations among

2FL02 adolescents with mood disorders, and high degree of depressive

2FL03 features in hypo(mania) (e.g., Kraepelin 1921; Hunt et al. 2009;

2FL04 Kowatch et al. 2005; Van Meter et al. 2016), we chose to statistically

2FL05 control for symptoms in our planned analyses.

Table 2 Associations between manic and depression symptoms with

discrete positive and negative emotions

KMRS KDRS

Positive emotions

Joy .15* -.28*

Interest .03 .01

Surprise .03 .11

Negative emotions

Sadness -.10** .37*

Anger .00 .26*

Self-directed hostility -.05 .28*

Shame -.05 .22*

Guilt -.07 .24*

Disgust -.01 .15

Contempt .10 .07

Fear -.06 .19*

Shyness -.08 .27*

Correlations of KDRS and emotions are controlling for KMRS;

Correlations of KMRS and emotions are controlling for KDRS

KDRS KSADS Depression Rating Scale, KMRS KSADS Mania

Rating Scale

* p\ .01; ** p\ .05

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482 other emotions (i.e., shame, anger, disgust, contempt,

483 shyness, fear, interest, surprise) using the same analytic

484 approach described above (Blumberg and Izard

485 1985, 1986). As shown in Table 4, KMRS scores and

486 demographic variables (Block 1), were significant

487 (R2= .35) with control variables of age (b = .20,

488 p\ .001), gender (b = .15, p = .002), and KMRS

489 (b = .50, p\ .0005) scores predicting KDRS scores.

490 When hypothesized emotions of interest were added in

491 Block 2, the overall model was significant (R2= .43,

492 DR2= .08), with age (b = .154, p = .001) and KMRS

493 scores (b = .48, p\ .0005) remaining significant, along

494 with the emotions of joy (b = -.16, p\ .0005) and sad-

495 ness (b = .18, p = .01). None of the emotions added in

496 Block 3 were significant predictors. In the final Block,

497bipolar diagnosis was not a significant predictor

498(b = -.03, p = .68; DR2= .00). Age (b = .15,

499p = .001), KMRS scores (b = .51, p\ .001), and joy

500(b = -.19, p\ .0005) were also significant predictors in

501the final model; predictors accounted for 44 % of the

502variance in depression scores.

503Finally, net regression analysis, was used to test whether

504any of the emotion scores or demographic variables were

505uniquely related to the mood symptom scales (See

506Table 5). The results indicated joy is more strongly related

507to mania scores than to depression scores (p = .002).

508Additionally, older age was more strongly associated with

509depression scores than mania scores (p = .005). The other

510emotion variables did not have a stronger relation with

511either mood symptom scale.

Table 3 Hierarchical multiple

regression analyses using

mania-relevant emotions to

predict current manic symptoms

Predictor KMRS KMRS (not controlling for KDRS)

DR2 b DR2 b

Block 1: demographics and symptoms .29*** .03*

Age -.10* .01

Female .02 .13*

Caucasian .08 .14*

KDRS .54*** –

Block 2: mania-relevant emotions .03** .03*

Joy .12* .02

Anger -.03 .08

Contempt .11* .13*

Block 3: other emotions .01 .01

Joy .15* .05

Anger .04 .09

Contempt .13* .14*

Shyness -.06 .02

Guilt -.05 -.05

Disgust .03 -.04

Self-directed hostility -.03 .07

Shame .02 -.02

Fear -.00 -.04

Interest -.07 -.05

Surprise -.02 .04

Sadness -.07 .03

Block 4: diagnosis .37*** .58***

Joy .03 -.02

Anger .01 .02

Contempt .04 .03

BPSD diagnosis .69*** .79***

Mania relevant emotions shown in Block 2 and subsequent Blocks 3 and 4

KDRS KSADS Depression Rating Scale, KMRS KSADS Mania Rating Scale, BPSD bipolar spectrum

disorder

* p\ .05; ** p\ .01; *** p\ .001

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512 Discussion

513 Research on positive emotion disturbance has gained

514 increasing attention, yet it has remained less clear the

515 concurrent and likely bidirectional relationship between

516 positive emotions and mood symptoms during the critical

517 period of adolescence. This is especially pertinent for

518 identifying potential endophenotypic markers associated

519 with illness onset and course. We investigated associations

520 between mood symptoms and self-reported positive and

521 negative emotions in a large adolescent outpatient sample.

522 Results suggested unique associations between symptoms

523 of mania with both increased joy and contempt, and

524 between symptoms of depression with both increased

525sadness and decreased joy. These patterns were indepen-

526dent of specific diagnosis, underscoring the importance of

527adopting a dimensional approach to thinking about mood

528pathology (Helzer et al. 2006; Insel et al. 2010; Sanislow

529et al. 2010). These findings extend work on specific emo-

530tions implicated in mood pathology in adulthood, and

531illuminate associations between emotions associated with

532goal driven behavior with mood symptom severity in

533adolescence.

534The first aim assessed the relationship between specific

535emotions with symptoms of mania in adolescents. Con-

536sistent with our predictions, symptoms of mania were

537associated with joy and contempt, but not with any other

538positive or negative emotions. With respect to joy, these

Table 4 Hierarchical multiple

regression analyses using

depression-relevant emotions to

predict current depressive

symptoms

Predictor KDRS KDRS (not controlling for KMRS)

DR2 B DR2 b

Block 1: demographics and confounds .35*** .11***

Age .19*** .20***

Female .14** .21***

Caucasian .04 .11

KMRS .50*** –

Block 2: depression-relevant emotions .08*** .10***

Sadness .17* .21**

Self-directed hostility .03 .06

Guilt .04 .01

Joy -.16*** -.13*

Block 3: other emotions .02 .02

Sadness .16 .17

Self-directed hostility .03 .06

Guilt .03 .00

Joy -.20*** -.17**

Disgust -.09 -.11

Contempt -.06 .01

Shyness .13 .14

Fear -.04 -.06

Interest .06 .04

Surprise .08 .10

Anger .04 .08

Shame -.07 -.08

Block 4: diagnosis .00 .13***

Sadness .15 .20*

Self-directed hostility .03 .05

Guilt .03 -.02

Joy -.19*** -.21**

BPSD diagnosis -.03 .37***

Depression relevant emotions shown in Block 2 and subsequent Blocks 3 and 4

KDRS KSADS Depression Rating Scale, KMRS KSADS Mania Rating Scale, BPSD bipolar spectrum

disorder

* p\ .05; ** p\ .01; *** p\ .001

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539 findings dovetail with a growing literature suggesting

540 mania symptoms involve a heightened focus on the pursuit

541 of rewards and ambitious goals (Alloy and Abramson

542 2010; Johnson 2005; Meyer et al. 2001). Importantly in the

543 emerging adolescent literature, these findings are consistent

544 with work among outpatient adolescents suggesting that

545 reward-relevant positive emotions were concurrently

546 associated with increased manic symptom severity (Gruber

547 et al. 2013). This work also is also consistent with research

548 in adults with BPSD suggesting that increased reward

549 sensitivity is concurrently associated with increased manic

550 symptoms, providing encouraging support for develop-

551 mental continuity in positive associations between reward-

552 relevant emotions and mania symptoms (Alloy and

553 Abramson 2010; Johnson 2005; Meyer et al. 2001; Uro-

554 sevic et al. 2008). Our findings are also aligned with the

555 adult literature suggesting that adults at risk for mania

556 show unique elevations in self-reported positive emotions

557 like joy, but not other types of other-oriented or low-

558 arousal positive emotions (Gruber and Johnson 2009).

559 These findings are also consistent with emerging literature

560 suggesting that heightened reward sensitivity—which

561 covaries with the experience of emotions like joy—may

562represent a candidate risk indicator for, and targeted

563treatment foci of, bipolar disorder (e.g., Alloy et al. 2015;

564Duffy et al. 2015). Interestingly, results between emotions

565and mania were only significant when controlling for

566depressive symptoms, but results held for depression when

567controlling manic symptoms. There are several potential

568interpretations of these results including potential covari-

569ation in symptom presentation common in mixed states,

570reliance on caregiver reports for symptom ratings scales

571which may be less sensitive to identifying manic versus

572depressive symptoms (e.g., Freeman et al. 2011; Young-

573strom et al. 2015). Future work is warranted to continue to

574probe these and other possibilities, underscoring the

575importance of detecting underlying mechanisms, such as

576trait affect, driving both mood symptom presentations.

577Taken together, these findings suggest that increased manic

578symptoms during this critical neurodevelopmental phase

579may also be tied to emotional experiences related to goal

580pursuit and attainment. It will be important to continue to

581examine the role of specific types of positive emotionality

582in the developmental trajectory of BPSD across time, with

583a particular focus on reward-related positive states.

584Additionally, the results indicating an association

585between contempt and manic symptoms in adolescence is

586consistent with work that has found heightened contempt

587among both adult (e.g., Dutra et al. 2014, 2016) and ado-

588lescent (Leibenluft 2011) bipolar populations. Importantly,

589elevations in contempt have been associated with height-

590ened sensitivity of the Behavioral Approach System (Car-

591ver 2004; Harmon-Jones and Allen 1998), a central process

592implicated in the etiology of BD (Urosevic et al. 2008).

593This suggests that heightened contempt may arise when

594goal pursuit is thwarted and subsequently trigger the gen-

595eration and exacerbation of mania in adolescents as well as

596adults (e.g., Johnson 2005). High levels of contempt may

597also help to explain the conflict and stressful interpersonal

598relationships common among adolescents with bipolar

599disorder (Algorta et al. 2011; Coville et al. 2008; Du

600Rocher Schudlich et al. 2008; Siegel et al. 2015), given a

601robust literature associating contempt with distinctly toxic

602effects in interpersonal relationships (Gottman 1994).

603The second aim assessed the relationship between

604specific emotions with symptoms of depression in adoles-

605cents. Consistent with our predictions, symptoms of

606depression were uniquely associated with decreased joy

607and increased sadness, but not with any other positive or

608negative emotions, findings that also held when controlling

609for symptoms of mania and bipolar diagnosis. These results

610converge with robust findings in adults that postulate a core

611feature of depression involves decreased pleasure and

612approach towards goals (Alloy and Abramson 2010;

613Davidson et al. 2002; Dillon and Pizzagalli 2010) and

614decreased positive affectivity more generally (Brown et al.

Table 5 Net regression analyses using emotions and covariates (age,

sex, race) to predict the difference between the predicted BDI score

for each participant, based on the IVS, and his/her true KMRS score

(i.e., KMRS–KDRS)

Predictor KMRS–KDRS

DR2 B

Block 1: demographics .05***

Age -.11**

Female -.16

Caucasian .06

Block 2: emotions .09***

Sadness -.53

Anger .03

Self-directed hostility .01

Joy .93**

Shame .22

Guilt -.21

Interest -.37

Surprise -.26

Disgust .34

Contempt .54

Shyness -.51

Fear .09

KDRS KSADS Depression Rating Scale, KMRS KSADS Mania

Rating Scale

* p\ .05; ** p\ .01; *** p\ .001

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615 1998; Chorpita and Daleiden 2002; Clark and Watson

616 1991; McMakin et al. 2011), which would be reflected in

617 reduced joy. Our results associating increased sadness with

618 depression symptoms are highly convergent with clinical

619 observations (American Psychiatric Association 2013) and

620 extant empirical work associating depression with

621 increased reports of sadness in adults (e.g., Rottenberg

622 et al. 2002). In addition, these results are supported by

623 work linking sadness measured from a similar DES-IV

624 self-report scale to prospective prediction of depression

625 symptoms at a 4-month follow-up in children (Blumberg

626 and Izard 1985, 1986). In RDoC terms, depression involves

627 at least two major domains: increased negative affect, and

628 decreased positive affect—corresponding to anhedonia and

629 loss of interest as core features, and the ‘‘low PA’’ com-

630 ponent of the tripartite model of depression and anxiety

631 (Clark and Watson 1991). Future work should explore

632 whether emotion-regulation strategies that feed sadness

633 levels heighten adolescent depression (e.g., Millgram et al.

634 2015).

635 The results of the present study need to be interpreted

636 within the confines of several limitations. First, the results

637 of the present study were assessed exclusively with self-

638 report indices of emotional states. Although this repre-

639 sented a good first step, future studies should utilize

640 experimental inductions of distinct types of emotional

641 states (e.g., emotion-eliciting films or images) and mea-

642 suring concurrent physiological and behavioral indices of

643 reward sensitivity. In addition, it will be valuable to more

644 carefully examine a broader array of distinct positive

645 emotional states moving forward. Second, the sample was

646 comprised of a demographically diverse sample that con-

647 tained a high percentage of low-income African-American

648 adolescent families. Although this represents a strength of

649 the present research by representing underserved and

650 understudied minority groups, it may complicate direct

651 comparisons with previous work. Third, we did not assess

652 for pubertal status and its influence on emotion experience,

653 especially important given differences in reward process-

654 ing associated with pubertal timing. Fourth, the current

655 study was cross-sectional and, as such, a longitudinal

656 prospective high-risk sample design is warranted to more

657 clearly disentangle the causal relationship between emo-

658 tions and mood symptoms.

659 Despite these limitations, the present study adds to the

660 small, but growing, literature examining associations

661 between emotional experience and mood symptom sever-

662 ity, extending this work in a demographically diverse

663 adolescent sample. Such findings advance our under-

664 standing of the relevance of these valenced systems in the

665 etiology of mood psychopathology and targeted remedia-

666 tion with an explicit focus on emotional processing. The

667 availability of free scales that measure focal constructs

668such as contempt and joy make it possible for both

669researchers and clinicians to examine the relevance of these

670constructs (Izard et al. 1993). Future steps include should

671identifying behavioral and pathophysiological processes

672associated with disrupted emotion processes in adolescents

673that may ultimately inform preventative treatment

674development.

675Acknowledgments This work was supported in part by NIH R01676MH066647 to Eric Youngstrom. Dr. Youngstrom has consulted with677Pearson, Otsuka, Janssen, Lundbeck, Joe Startup Technologies, and678Western Psychological Services about psychological assessment. Dr.679Findling receives or has received research support, acted as a con-680sultant, received royalties from, and/or served on a speaker’s bureau681for Abbott, Addrenex, Alexza, American Psychiatric Press, Astra-682Zeneca, Biovail, Bristol-Myers Squibb, Dainippon Sumitomo683Pharma, Forest, GlaxoSmithKline, Guilford Press, Johns Hopkins684University Press, Johnson and Johnson, KemPharm Lilly, Lundbeck,685Merck, National Institutes of Health, Neuropharm, Novartis, Noven,686Organon, Otsuka, Pfizer, Physicians’ Post-Graduate Press, Rhodes687Pharmaceuticals, Roche, Sage, Sanofi-Aventis, Schering-Plough,688Seaside Therapeutics, Sepracore, Shionogi, Shire, Solvay, Stanley689Medical Research Institute, Sunovion, Supernus Pharmaceuticals,690Transcept Pharmaceuticals, Validus, WebMD and Wyeth.

691Compliance with Ethical Standards

692Conflict of Interest June Gruber, Anna Van Meter, Kirsten Gilbert,693Jennifer Kogos Youngstrom, and Norah Feeny declare that they have694no conflict of interest.

695Informed Consent Informed consent procedures were followed in696accordance with the ethical standards of the responsible committees697on human experimentation at the University Hospitals of Cleveland698and Applewood Centers. Informed consent was obtained from all699individual subjects participating in the study.

700Animal Rights No animal studies were carried out by the authors for701this article.

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1047Urosevic, S., Abramson, L., Harmon-Jones, E., & Alloy, L. (2008).1048Dysregulation of the behavioral approach system (BAS) in1049bipolar spectrum disorders: Review of theory and evidence.1050Clinical Psychology Review, 28(7), 1188–1205. doi:10.1016/j.1051cpr.2008.04.004.1052Uusitalo-Malmivaara, L. (2014). Happiness decreases during early1053adolescence—A study on 12- and 15-year-old finnish students.1054Psychology, 05, 541–555. doi:10.4236/psych.2014.56064.1055Van Meter, A. R., Burke, C., Kowatch, R. A., Findling, R. L., &1056Youngstrom, E. A. (2016). Ten-year updated meta-analysis of1057the clinical characteristics of pediatric mania and hypomania.1058Bipolar Disorders. doi:10.1111/bdi.12358.1059Van Meter, A., Moreira, A. L., & Youngstrom, E. A. (2011). Meta-1060analysis of epidemiological studies of pediatric bipolar disorder.1061Journal of Clinical Psychiatry, 72, 1250–1256. doi:10.4088/JCP.106210m06290.1063Watson, D., & Naragon-Gainey, K. (2010). On the specificity of1064positive emotional dysfunction in psychopathology: Evidence1065from the mood and anxiety disorders and schizophrenia/schizo-1066typy. Clinical Psychology Review, 30, 839–848.1067Youngstrom, E. A., Birmaher, B., & Findling, R. L. (2008a). Pediatric1068bipolar disorder: Validity, phenomenology, and recommenda-1069tions for diagnosis. Bipolar Disorders, 10, 194–214. doi:10.10701111/j.1399-5618.2007.00563.x.1071Youngstrom, E. A., Findling, R. L., Danielson, C. K., & Calabrese, J.1072R. (2001). Discriminative validity of parent report of hypomanic1073and depressive symptoms on the General Behavior Inventory.1074Psychological Assessment, 13(2), 267–276. doi:10.1037//1040-10753590,13.2.267.1076Youngstrom, E. A., Findling, R. L., Kogos Youngstrom, J., &1077Calabrese, J. R. (2005a). Toward an evidence-based assessment1078of pediatric bipolar disorder. Journal of Clinical Child and

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